“Sinus” Headaches: Diagnosis and Treatment

Editor’s Note: The following is an excerpt from Dr. O’Halloran’s book: The Nose For Non-ENT Physicians.

Facial Pain, Pressure, “Sinus” Headache

Diagnosis

Chronic pressure and/or pain in the cheeks, around or behind the eyes. Often described as a “sinus” headache without other symptoms of acute sinusitis. May be unilateral or bilateral.

Underlying problem

Turbinate swelling, an abnormally enlarged middle turbinate bone (concha bullosa) and/or a deviated nasal septum. The swollen or enlarged turbinates press against the septum or lateral nasal wall to cause pain and pressure. A septal deviation can be impacted into an inferior or middle turbinate to cause pain and pressure. A more appropriate term is a nasal headache if no evidence of sinusitis is found.

Treatment

Medical treatment is focused on decreasing nasal turbinate swelling with decongestants or nasal steroid sprays. I symptom relief is not achieved after an appropriate trial of medical therapy, referral and/or imaging studies should be obtained to rule out chronic sinusitis, tumors and anatomic deformities.

Many patients will have already tried oral or spray decongestants with variable success. Overuse of nasal decongestant sprays is common in patients with “sinus” headaches and should be avoided. Oral decongestants often work well for patients with occasional symptoms.

Surgical correction of a deviated septum that is impacted against the lower or middle turbinate often but not always relieves nasal headaches and facial pain if the pain is located on the side of the deformity. Surgery can also correct an abnormally enlarged middle turbinate bone (concho bullosa), which will often relieve facial pain and nasal headaches. The results of surgery to alleviate facial pain and headache are not always predictable, but an estimate of success can be attained by performing a topical anesthesia test.

Case: Sinus Headaches

Anne Marie, a 28 year old actress, complained of persistent, severe “sinus” headaches, yet sinus x-rays were negative. Oral decongestants sometimes helped; antihistamines were ineffective. She had previously used a nasal steroid spray for 2 weeks with no relief and the spray had caused her nose to become dry and crusted on the anterior septum. Her headaches were crippling, and she was crying in the office during our visit.

Examination revealed a markedly congested nose with swollen nasal turbinates as well as a deviated nasal septum impacting into the inferior turbinate. It was not clear if the nasal turbinate congestion, the deviated septum, or both were responsible for her headaches.

Anne Marie was instructed to try the nasal steroid spray again, this time applying a small amount of petroleum jelly to the anterior septum and aiming the spray lightly away from the septum. She was instructed to use the spray for 6 weeks before assessing results. She somewhat reluctantly agreed to this treatment plan. At her follow-up appointment 6 weeks later, she reported complete relief of her “sinus” headaches. She continues to use the steroid spray and has no problems with intranasal dryness. She stated that using the nasal steroid spray had “changed her life.” At this time, she does not feel that she needs to have the nasal septum straightened.

He sees patients at the FamilyHealth Medical Clinic in Lakeville. The Lakeville clinic is convenient for residents of Lakeville, Rosemount, Burnsville, Eagan, Bloomington, Edina, Minneapolis and surrounding communities. Please call (952) 469-0500 to schedule an appointment in Lakeville.

Dr. O’Halloran also sees patients at the O’Halloran Clinic in Faribault. The O’Halloran Clinic is convenient for residents of Faribault, Owatonna, Waseca and surrounding communities. Please call (507) 333-5499 to schedule an appointment in Faribault.